Provider Demographics
NPI:1801200795
Name:GAGE, DANA (PTA)
Entity type:Individual
Prefix:MS
First Name:DANA
Middle Name:
Last Name:GAGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MESILLA DR APT 3
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-1545
Mailing Address - Country:US
Mailing Address - Phone:505-716-6942
Mailing Address - Fax:
Practice Address - Street 1:450 PROSPECTOR AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7940
Practice Address - Country:US
Practice Address - Phone:505-716-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013298261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation